In the state of Uttar Pradesh in northern India,
nearly 500,000 children are born every month. And for the Global
Polio Eradication Initiative (GPEI), each one must be immunized
for polio. Actually, all children under the age of 5 are vaccinated in
each polio round, which takes place monthly in high-risk areas.
That’s 170 million children vaccinated each year—quite a feat.

To accomplish this, an army of health workers, from the World
Health Organization (WHO), UNICEF, and the Indian government,
blanket Uttar Pradesh’s high-risk areas with polio booths and door-to-door visits. After 27 years, their efforts have begun to pay off.
Last year, India didn’t report a single new case of the disease.

In fact, the last confirmed case of poliomyelitis was an
18-month-old girl from the Howrah district of Kolkata in West
Bengal—far from the hotbed of polio. To date, the focus has been
on Uttar Pradesh and Bihar, two states known for dense population,
low incomes, and poor
sanitation. Just three years ago,
decades into the campaign,
Uttar Pradesh and Bihar still
produced more than 700 cases
of polio. In 1985, when GPEI
began, India had 150,000 cases.

Driving from Delhi to Uttar
Pradesh, it’s easy to see how disease
can spread. People are in
constant supply. The state has a
population of approximately 200
million people, or two-thirds of
the US population. They live
with an endless maze of open
sewers, piles of trash, and pools
of stagnant water; it’s evident
why polio survived for so many
years here. Transmitted through
contact with fecal matter, the
virus can survive in the gut for a month, without showing any signs.
An infected child can infect 200 more in the area, and the cycle continues,
enveloping a community quickly.

That’s why India’s polio-free year has made headlines globally.
Although India’s neighbors Afghanistan and Pakistan, along with
Nigeria, continue to be polio-endemic countries, India has now
been taken off that list. Even with the burgeoning population,
migratory challenges, contaminated water supply, and poor infrastructure,
India has succeeded.

“No one thought it could be done here, given the circumstances,”
says Rod Curtis, communications development specialist
for UNICEF. “So if Uttar Pradesh and Bihar can do it, that’s a
strong indicator for other regions battling this as well.”

Although health workers are quietly celebrating, the journey to
becoming polio-free has been long and strenuous. The key has been
the multilayered, weblike infrastructure of partners, donors, and
health workers that make up the GPEI in India. While UNICEF
works primarily on communication (posters, coordinating health
workers, and informing the public), WHO provides its medical
expertise, testing stool samples for possible polio cases, checking
polio booths, tracking the virus, and maintaining
the correct conditions for the supply
of the vaccine. Rotary International, the
third partner, has taken the polio campaign
to an international stage, raised funds for it,
and pressed public officials to make it a priority.
The Bill & Melinda Gates Foundation
and the Indian government round out this
collaboration, along with the US Centers
for Disease Control and Prevention.

The immensity of the Indian campaign
can be hard to grasp. There are more than
700,000 vaccination booths in every campaign
led by 2.5 million vaccinators, who
have 2 million vaccine carrier bags, which
are kept cool with 6.3 million ice packs. In
one national polio round, more than 200
million homes were visited and more than
170 million children were vaccinated.
Because of the breadth of the campaign,
funding is essential. Most recently, the
Gates Foundation pledged $355 million
and Rotary International provided more
than $200 million.

The immensity of the Indian campaign is hard to grasp. There are 700,000 vaccination booths led by 2.5 million vaccinators, who have 2 million vaccine carrier bags, kept cool with 6.3 million ice packs.

India stands out among the other polio-endemic
countries in another way: The
Indian government has contributed nearly
$2 billion to the effort. Government support
comes from the national level—including President Pratibha Patil, who launched this year’s
National Immunization Day, and Prime Minister Manmohan Singh,
who opened the 2012 Rotary Polio Summit in Delhi—as well as
from district-level magistrates, who participate in immunization
rounds and meet with health workers for regular assessments.

Additional buy-in has come from UNICEF community mobilizers,
government-sponsored ASHA (Accredited Social Health Activists)
workers, local WHO staff, and religious leaders. At the microlevel,
WHO staff and UNICEF workers meet regularly,
exchanging information, coordinating
efforts, and identifying trouble spots. The
dialogue is constant, especially during immunization
rounds, with debriefing sessions
taking place every evening.

This web of coordination and collaboration
has enabled GPEI to penetrate
dense neighborhoods, remote villages, and
makeshift colonies, eradicating one of the
most dreaded childhood diseases in human history. It is an infrastructure
that now can serve as a blueprint for future public
health campaigns.

Grassroots Buy-In

I first visited one of north India’s high-risk areas in 2008. It was a
four-hour car ride from Delhi on Uttar Pradesh’s potholed roads to
Aligarh—a city with polio cases as well as resistance to the vaccine.
Health workers found resentful families unwilling to get their
children vaccinated. The reasons tended to arise from safety concerns:
Among Muslims, a rumor had spread that the vaccine would
make their children impotent and was a ploy to minimize their
community. It was baseless. But the damage was severe, as more
polio cases were found among Muslims with an increasing number
of parents forgoing regular visits to the polio vaccination booths.

To combat the false rumor, the Rotary polio office in Delhi
consulted with the National Ulema (Muslim clerics), encouraging
them to show their support for the vaccine. The clerics complied.
They wrote notes of affirmation, in the local language (Urdu),
which were used by health workers to convince hesitant families
that the vaccine was safe.

Four years later, these kinds of problems have dissipated. In
2012, as I walked through the same neighborhoods with Mohd
Umar, the local polio coordinator, health workers came to greet
him, mothers said hello, and children swarmed around him. As he
took me through some of the same alleys, each house was marked
with chalk, indicating that the children there had been vaccinated.
Today there’s little resistance to the health incursion. Rather, the
locals talk about the water supply and the pumps provided by
local politicians, adorned with their party symbol. Some of the
pumps are clean; others are sitting amidst piles of garbage, pools
of stagnant water, and animal waste.

The dusty alleys, bordered with makeshift homes, lead to a
pool of standing water in the heart of the community. It’s already
knee-high, and it’s only February. When the monsoon rains come,
it will rise. Umar pauses. He knows that even if polio is eradicated
from India, dirty water will continue to pose a threat.

Indeed, dirty water has been an encumbrance to the polio
effort. Because children are prone to getting dysentery from contaminated
water, they struggle to keep the vaccine in their bodies.
It quickly passes through them. As a result, children have to be
vaccinated repeatedly.

Health workers walk with chalk and black ink here. They chalk
the doors, signaling that a house has been reached, and ink the
pinky finger of the child, letting other health workers know that
he or she has received the vaccine. The
teams set up booths through the town.
They’re simple constructions: a bench and a
table with a polio banner or simply the front
of a shop, adorned with a polio poster. In
addition, health workers station themselves
at train stations, migration points, and other
populous locations, searching for that uninked
pinky. “Here children cannot be
tracked. They don’t go to school. They move
where their parents move,” says Umar.

This migratory population is what concerns the polio team.
Nima Chodon, communications officer of the India National Rotary
PolioPlus Office, explains that these migrations can lead to flareups.
The last case of polio in Kolkata was traced back to Delhi and
finally to Bihar. Flare-ups have been a recurrent trend in the polio
story. Although health workers are able to contain it in one region,
it tends to return elsewhere. Last year’s flare-ups in the Congo and
Central Asia have all been linked back to India, and in particular to
Bihar. To combat this, vaccinations are taking place along the Nepal
and Pakistan borders, and WHO is regularly testing the environment
in Delhi to see if the virus is on the move.

Among this army of health workers is Dr. Aikant Bhatti, whom
I met on National Immunization Day as he was surveying the
neighborhoods of West Delhi. A young man who walks fast, speaks
with passion, and works efficiently, he is a good example of GPEI’s
grassroots support. Asked why he didn’t leave his post as a surveillance
medical officer at WHO and take up a more lucrative or
prestigious profession, he smiles and says simply, “Once you come
out here and you do this, you can’t really walk away from it.”

Many wonder whether India’s success can be repeated in
neighboring Afghanistan and Pakistan, where polio still lurks. Dr.
Arvind Singhal, a member of the Independent Monitoring Board
for GPEI, is optimistic. “In India, GPEI relied on local buy-in, getting
members of the local community and religious groups to
help. And they slowly chipped away at the resistance. The same
local buy-in is needed in the other polio-endemic countries, where
they are facing resistance.”

Tim Peterson, a polio expert with the Gates Foundation,
echoed that sentiment. “For the kind of noncompliance that we’re
seeing in Nigeria right now and the mistrust in Pakistan and
Afghanistan, we need to understand why the vaccinators are being
refused. In India, we did that. We understood exactly why certain
children were being missed. We kept going back to them until we
figured it out. So we need to raise the quality of the campaign to
that level in the other countries and really get a deep understanding
of what’s missing.”

Esha Chhabra is a writer who focuses on social innovation, social enterprises, and technology for development. She is a graduate of the London School of Economics and Georgetown University.